Michael J. Barrett

Efficacy of Angiotensin-Converting Enzyme Inhibitors and Beta-Blockers in the Management of Left Ventricular Systolic Dysfunction According to Race, Gender, and Diabetic Status A Meta-Analysis of Major Clinical Trials

OBJECTIVES This study sought to assess the effect of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers on all-cause mortality in patients with left ventricular (LV) systolic dysfunction according to gender, race, and the presence of diabetes. BACKGROUND Major randomized clinical trials have established that ACE inhibitors and beta-blockers have life-saving benefits in patients with LV systolic dysfunction. Most patients enrolled in these trials were Caucasian men. Whether an equal effect is achieved in women, non-Caucasians, and patients with major comorbidities has not been established. METHODS The authors performed a meta-analysis of published and individual patient data from the 12 largest randomized clinical trials of ACE inhibitors and beta-blockers to produce random effects estimates of mortality for subgroups. RESULTS Data support beneficial reductions in all-cause mortality for the use of beta-blockers in men and women, the use of ACE inhibitors and some beta-blockers in black and white patients, and the use of ACE inhibitors and beta-blockers in patients with or without diabetes. Women with symptomatic LV systolic dysfunction probably benefit from ACE inhibitors, but women with asymptomatic LV systolic dysfunction may not have reduced mortality when treated with ACE inhibitors (pooled relative risk = 0.96; 95% confidence interval: 0.75 to 1.22). The pooled estimate of three beta-blocker studies supports a beneficial effect in black patients with heart failure, but one study assessing bucindolol reported a nonsignificant increase in mortality. CONCLUSIONS Angiotensin-converting enzyme inhibitors and beta-blockers provide life-saving benefits in most of the subpopulations assessed. Women with asymptomatic LV systolic dysfunction may not achieve a mortality benefit when treated with ACE inhibitors.

Ventricular aneurysm: Cross-sectional echocardiographic approach

Current angiographic indexes of ventricular function have proved inadequate for prognostication in patients with ventricular aneurysm. Cross-sectional echocardiography can visualize residual myocardium in all four walls of the left ventricle. A new echocardiographic technique of calculating residual myocardium is presented. The echocardiographic technique yielded identical information to that of contrast angiography (r = 0.97). An index of residual myocardium was generated from the cross-sectional echocardiogram that correlated with the clinical state of the patients. In patients treated medically it predicted those patients likely to die within 6 months (p < 0.005). Preliminary observations in patients having aneurysmectomy revealed that there were good surgical results in those with an index of residual myocardium of 0.42 or greater, but more patients are necessary to establish the lower limit of a surgically acceptable level of residual myocardium.

Dynamic Changes in Left Ventricular Geometry and Pressure During Coronary Artery Occlusion in Man

Analysis of the early left ventricular geometry and hemodynamic response to the abrupt occlusion of a major coronary artery has not been feasible in man thus far.